A Worrisome Case of Early In Situ Melanoma on the Leg: A ...
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Brief Report Vol. 33, No. 5, 2021 477 Received January 16, 2020, Revised June 15, 2020, Accepted for publication July 15, 2020 Corresponding author: Takahiro Kiyohara, Department of Dermatology, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka 570-8507, Japan. Tel: 81-6-6992-1001, Fax: 81-6-6993-9488, E-mail: kiyohart@ takii.kmu.ac.jp ORCID: https://orcid.org/0000-0002-8608-9071 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons. org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright © The Korean Dermatological Association and The Korean Society for Investigative Dermatology https://doi.org/10.5021/ad.2021.33.5.477 A Worrisome Case of Early In Situ Melanoma on the Leg: A Multicomponent Pattern in Dermoscopy Supportive of Malignancy Takahiro Kiyohara, Hirotsugu Tanimura Department of Dermatology, Kansai Medical University Medical Center, Osaka, Japan Dear Editor: Clinically, in situ melanoma (ISM) is a pigmented macule with an irregular border. There are often variations in col- or including not only tan, brown, and black, but also pink, blue, gray, and white. Dermoscopic criteria for the diag- nosis of melanoma on the trunk and extremities include a multicomponent pattern, atypical pigment network, irreg- ular dots/globules, irregular streaks, irregular pigmentation, blue-whitish veil, and regression structures 1 . A 64-year-old male presented with a 5 mm×4 mm-sized, asymmetric, black macule, accompanied by an irregular edge on his right leg (Fig. 1A), with 2 years’ duration. Der- moscopy demonstrated a multicomponent pattern with an atypical pigment network, irregular dots/globules, irregu- lar streaks, and homogeneous areas. There were light and dark brown colors (Fig. 1B). Histological examination de- monstrated an asymmetrical silhouette. The epidermis was irregularly thickened and thinned. Patterns of inflamma- tory infiltrates and melanin deposits were also asymmetri- cal. Partial fibrosis was seen in the subepidermal area. One half of the lesion did not mirror the other half (Fig. 1C). There was a contiguous proliferation of atypical page- toid cells completely replacing the basal cells, accompa- nied by only a few nests (Fig. 1D). These cells had hyper- chromatic nuclei and a few mitoses (Fig. 1E). Pagetoid spread could not be seen. Immunohistochemically, atypi- cal pagetoid cells were positive for S-100 protein (Fig. 1F), HMB45, and melan-A. The patient was diagnosed with early ISM. Computed tomography and fluorodeoxyglucose- position emission tomography revealed no evidence of malignancies. A wide local excision with a 1-cm margin was performed three weeks after an excisional biopsy with a 1-mm margin. Neither local recurrence nor metastasis has appeared during the 7-year follow-up. Two major patterns of ISM can be distinguished from each other: pagetoid and lentiginous. The term “pagetoid” origi- nally connoted the spread of single melanocytes and small nests of such cells above the basal layer, as seen in mam- mary and extramammary Paget’s diseases. However, it is also, although less often, used as a cytologic description of certain melanocytes, conveying the presence of abundant pale cytoplasm 2 . Pagetoid spread is graphically described as buckshot scatter of melanocytes within the epidermis, the best-known pattern of superficial spreading melanoma. At the earliest time of development in ISM, exclusive sin- gle melanocytes proliferate in the basal layer. The present case corresponded to early ISM because of the lack of pa- getoid cells above the basal layer. In both clinical and der- moscopic aspects, obvious characteristics of melanomas are hard to be detected in small ISMs. In the present case, melanoma might be suspected clinically by asymmetry with an irregular edge despite the small size of 5 mm. Asymmetry has been reported to be an important finding for early diagnosis of melanoma 3 . Furthermore, a multi- component pattern could be detected in dermoscopy. Otherwise, Clark’s nevi usually reveal regular reticular or globular patterns. Although histologic examination remains the gold standard for an accurate diagnosis of melanoma 4 , a multicomponent pattern in dermoscopy could be an im- portant key 5 .
Transcript of A Worrisome Case of Early In Situ Melanoma on the Leg: A ...
Brief Report
Vol. 33, No. 5, 2021 477
Received January 16, 2020, Revised June 15, 2020, Accepted for publication July 15, 2020
Corresponding author: Takahiro Kiyohara, Department of Dermatology, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka 570-8507, Japan. Tel: 81-6-6992-1001, Fax: 81-6-6993-9488, E-mail: kiyohart@ takii.kmu.ac.jpORCID: https://orcid.org/0000-0002-8608-9071
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright © The Korean Dermatological Association and The Korean Society for Investigative Dermatology
https://doi.org/10.5021/ad.2021.33.5.477
A Worrisome Case of Early In Situ Melanoma on the Leg: A Multicomponent Pattern in Dermoscopy Supportive of Malignancy
Takahiro Kiyohara, Hirotsugu Tanimura
Department of Dermatology, Kansai Medical University Medical Center, Osaka, Japan
Dear Editor:Clinically, in situ melanoma (ISM) is a pigmented macule with an irregular border. There are often variations in col-or including not only tan, brown, and black, but also pink, blue, gray, and white. Dermoscopic criteria for the diag-nosis of melanoma on the trunk and extremities include a multicomponent pattern, atypical pigment network, irreg-ular dots/globules, irregular streaks, irregular pigmentation, blue-whitish veil, and regression structures1.A 64-year-old male presented with a 5 mm×4 mm-sized, asymmetric, black macule, accompanied by an irregular edge on his right leg (Fig. 1A), with 2 years’ duration. Der-moscopy demonstrated a multicomponent pattern with an atypical pigment network, irregular dots/globules, irregu-lar streaks, and homogeneous areas. There were light and dark brown colors (Fig. 1B). Histological examination de-monstrated an asymmetrical silhouette. The epidermis was irregularly thickened and thinned. Patterns of inflamma-tory infiltrates and melanin deposits were also asymmetri-cal. Partial fibrosis was seen in the subepidermal area. One half of the lesion did not mirror the other half (Fig. 1C). There was a contiguous proliferation of atypical page-toid cells completely replacing the basal cells, accompa-nied by only a few nests (Fig. 1D). These cells had hyper-
chromatic nuclei and a few mitoses (Fig. 1E). Pagetoid spread could not be seen. Immunohistochemically, atypi-cal pagetoid cells were positive for S-100 protein (Fig. 1F), HMB45, and melan-A. The patient was diagnosed with early ISM. Computed tomography and fluorodeoxyglucose- position emission tomography revealed no evidence of malignancies. A wide local excision with a 1-cm margin was performed three weeks after an excisional biopsy with a 1-mm margin. Neither local recurrence nor metastasis has appeared during the 7-year follow-up.Two major patterns of ISM can be distinguished from each other: pagetoid and lentiginous. The term “pagetoid” origi-nally connoted the spread of single melanocytes and small nests of such cells above the basal layer, as seen in mam-mary and extramammary Paget’s diseases. However, it is also, although less often, used as a cytologic description of certain melanocytes, conveying the presence of abundant pale cytoplasm2. Pagetoid spread is graphically described as buckshot scatter of melanocytes within the epidermis, the best-known pattern of superficial spreading melanoma. At the earliest time of development in ISM, exclusive sin-gle melanocytes proliferate in the basal layer. The present case corresponded to early ISM because of the lack of pa-getoid cells above the basal layer. In both clinical and der-moscopic aspects, obvious characteristics of melanomas are hard to be detected in small ISMs. In the present case, melanoma might be suspected clinically by asymmetry with an irregular edge despite the small size of 5 mm. Asymmetry has been reported to be an important finding for early diagnosis of melanoma3. Furthermore, a multi-component pattern could be detected in dermoscopy. Otherwise, Clark’s nevi usually reveal regular reticular or globular patterns. Although histologic examination remains the gold standard for an accurate diagnosis of melanoma4, a multicomponent pattern in dermoscopy could be an im-portant key5.
Brief Report
478 Ann Dermatol
Fig. 1. (A) A black macule without a variegation of color, measuring 5 mm×4 mm on the right leg (clinical view). (B) A multicomponent pattern with atypical pigment network, irregular dots/globules, irregular streaks, homogeneous areas, and multiple colors (dermoscopy). (C) An asymmetrical silhouette (H&E, original magnification ×40). (D) A contiguous proliferation and a few nests in the basal layer (H&E, original magnification ×200). (E) Atypical pagetoid melanocytes with hyperchromatic nuclei (H&E, original magnification ×400).(F) Positive reactivity for S-100 protein (immunohistichemistry, original magnification ×400). We received the patient’s consent form about publishing all photographic materials.
In conclusion, we described a worrisome case of early ISM, accompanied by an important key of a multicompo-nent pattern in dermoscopy.
CONFLICTS OF INTEREST
The authors have nothing to disclose.
FUNDING SOURCE
None.
ORCID
Takahiro Kiyohara, https://orcid.org/0000-0002-8608-9071 Hirotsugu Tanimura, https://orcid.org/0000-0002-5701-5743
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